Triage lights to distinguish patients in need. Image: triagelights / cc by-sa-3.0
A comment on the approval of the corona crisis published triage recommendations of the italian siaarti physicians
Triage — this is the sorting of patients in groups forward and subordinate to treat in a large massage of the availability resources. That has always been a delicate and stressful process.
The italian society for anasthesia, analgesia, reanimation and intensive care medicine (siaarti) has given the intensive care physicians who are currently no longer available to all the best covid-19-patients ventilation gates, in recent recommendations to the hand. In this way, you want to relieve the practitioners from having to answer your selection decisions, and you want to explicitly and communicate the criteria. The affected persons and their families interested in it also had to be made accessible to maintaining confidence in the public healthcare.
These concerns are comprehensible. I was currently in patient or more in italy, i did not find it suitable for tangling a practitioner between tur and angel in discussions about assignment decisions. If the criteria — more precisely: recommendations on criteria — now publicly made, you have to comment on them as well. This is what i want to do here. My confidence in the (italian) public healthcare system has not been trimmed by this publication. Rather, it suffered. The fact that italian media reports according to individual practicing physicians publicly denied the application of the recommendations or. I have refused, i find pleasing. But i wonder, for how many this is true.
The post is first on the string blog on the 15.3.2020 published.
1
The central passage of the paper is: resources that connect considerable shortage, were first reserved for those who have a high survival probability, and secondly [2] for those who rescued more years"più anni di vita salvata") reach konne, in view of [3] maximizing the benefit ("dei benefici") for the large number of persons.
In the third part of this formulation numbered by me, you can easily recognize the maxim of utilitarianism. The second part specifies the benefits to which it goes as years of rescued life. This means the years of life that are expected to be expected in a patient in the event of his treatment at the time of decision. With the first part of the formulation, probably not the absolute probability of survivability, but on the probability associated with the treatmentgrowth to get expelled. Otherwise you had to face loud ill people who survive with the ventilation quite sure, but already have a good prognosis without ventilation.
For uncertainties and disagreement within the medical profession on questions of distribution justice, you should have reason. The topic, as i said, is tricky and in the specialist literature is much controversial. To the experts who publish on the subject, the medical profession also also the standard sciences, ie the ethics and jurisprudence, but also the health concomities, as far as they are normative aubert what they like to do. All this is not easy to overlook. The medical group, which is responsible for the siaarti recommendations, has not expressed uncertainty. She has "the catastrophical medicine" occupy, for the "the ethical reflection" developed concrete instructions.
Of these, the quoted formulation follows an established consensus for dealing with existential scarcities, but can not be spoken. This applies to the questions of allocation of life-saving resources in general, which is also the subject of the allocation of donor organs. But it also applies to the interdisciplinary literature on the disaster medical triage, which differs from the more general allocation debate in a certain way.
Not every scarcity, not every existential, will definitely be classified as a catastrophe. Only for the catastrophic case — the case of a sudden, the regular resources held resources far-demanding mass corridor from the need — has that under the name "triage" well-known procedures established. Also the mass margin of wounded in wartime is payable. The traditional rule is here to use the resources in such a way that many people may survive. In the organallocation, for example, this is not the billing criterion. That’s what you can see that people are supplied with double transplant requirement if they are in line with other rules.
Why did the italian physicians replaced the criterion of maximizing the number of survivors through the criterion of maximizing years of rescued life? I do not know it. Maybe you’ve chosen the formulation yourself, maybe you’ve been troubled on me not well-known recommendations of an italian or foreign expert society. Maybe even carried out received contributions from non-medical professionals as a mapless, which are in reality highly conceivable. In any case, the change of the criterion is disturbing. Not only ames if the new rule has been implemented consistently, a triage-untypical distribution certificate (2). Above all, the change indicates that the complex funding logic of triage has been misunderstood (3).
2
If the rule is to use the scarce resources so that many people affected may survive the catastrophe, the traditional triage procedure results. It provides a classification in four groups: priority are difficult-to-treat patients who are safe or most likely to survive without the infringement treatment, but have a good prognosis when treated. In the second row, patients are treated whose opportunity to survive the disease is not irrelevant without treatment, but was still clear when treated. Not treated are easily affected patients who have a good forecast even without treatment. Until the location is also not (or or. Only palliative) are treated those difficult-to-affected patients who have a bad prognosis even in treatment.
If the rule is that many rescued years of life should be achieved, it looks different. First of all, to differentiate goods within the mentioned groups after age. This is not part of the traditional procedure. For coarse differences in time, there were also old people in the first group in favor of young people in the second group.
Specifically, and with the clearing of the probability of probability: in a sixty-year-old with a statistical remaining life expectancy of 20 years, who surgically dies without treatment (0% survival probability) and overlooking the treatment of 70%, the resource use provides computationally 14 years (70% of 20 to). This patient had to give way to a twenty-year-old with a statistical residual life expectancy of 60 years, who surl without treatment with significant probability (70%) and for treatment with security (100%). Because in this patient, resource use provides mathematically 18 years (60 minus 42, d. I. 70% out of 60).
I hope the example is clear enough. It shows that the criterion of maximizing the rescued years of life from practitioners demanded a crass of spacing from the view of medical needs. The adopted patients and their relief was expected to give up significant their own survival opportunities in favor of an augmentation of the chances of survival of persons, which also without this solidarity performance (or how should one call that?) already have significant opportunities for survival. Why should you do that? And how is it that such a thing as a result "the ethical reflection" can be present?
3
This makes us with the question of the greeting logic. First of all: here, too, you can not look over, patients in which the treatment in question is indexed and whatever you (albeit a small) survival chance (group 4), rathered to do without your chance in favor of other patients. The first patients first (group 1) are, unlike the twenty year, in our example, unlike the twenty year, are not much less needed.
The traditional procedure is also the returning of the patient of group 4 opposite the patient of group 2. This impregnation can not be buried over the idea of solidarity with much heavier concerned. She can (and she should, if you want to hold on to the triage practice), be justified with the idea that before the entry of a disaster, d. H. As long as no woman in which group he lands, all of us can be interested in maximizing the number of survivors. At this suspected consensus, we are then recorded, even if the catastrophe uses us in group 4.
This is not utilitarian justification. A utilitarian burial of the same rule was loud that a saved human life is something "valuable" and therefore two (other) resetted lives ceteris paribus are twice as valuable. From this fundamentation, and only from this, you can easily get to the modification of the maximandum that the siaarti recommendations have allowed: if (and as long as that) life is valuable, is a long life more valuable than a short. If the resources are not the most value-productive ("efficient") when you maximize the number of years of life instead of the number of survivors?
This speech fits for business enterprises who have owners who are the values produced. She does not fit for health care. People have no owners. For the public hand, two human life are not "valuable" as a single other and, of course, twenty-year-old not more valuable than sixty-year-old.
At this principle should and can also be recorded in the corona crisis. This can work if you are accompanying a necessary triage especially on your non-stilitarian rearance. It succeeds best if you do not have the health policy distribution process as the law has always been doing inerms of benefits or values, but inerms written by right.
Like every lawyer, the individual’s rights of the individual must not automatically soften, just because they see them more individual individuals. Rights function "nonaggregative". In scarcity layers they are not maximized but specified in a fair way. That too is printing and difficult. But you can do it without in reflections on the (remaining) value of human life.
Prof. Dr. Weyma lubbe teaches philosophy at the university of regensburg (legal philosophy, social philosophy, political philosophy, ethics and applied ethics). She was a member of the german ethics council in 2008 to 2012.